Contextual factors influencing the urban mobility infrastructure interventions and policies for older adults in low and middle

Contextual factors influencing the urban mobility infrastructure interventions and policies for older adults in low and middle income countries a realist review Patil et al BMC Public Health (2022) 22.

Contextual factors influencing the urban

mobility infrastructure interventions

and policies for older adults in low-

and middle-income countries: a realist review

Divya Sussana Patil1*, Ajay Bailey1,2, Uday Narayan Yadav3,4, Sobin George5, Marco Helbich2, Dick Ettema2 and

Abstract

Transportation is among the key aspects that influence active ageing This realist review intends to understand the mechanisms of urban mobility infrastructure interventions and policies in low- and middle-income countries for older adults and to identify factors, which influenced the success or failure of interventions We followed the steps sug-gested by Pawson and colleagues for a realist review Electronic databases were searched from inception until August

2020 Studies were screened based on titles, abstracts and full text The quality of included studies was assessed based

on rigour and relevance The evidence was obtained from 36 articles with diverse study designs conducted in 36 low- and middle-income countries Findings were validated through stakeholder consultations from three low- and middle-income countries Of the various individual factors identified, behaviour change communication interven-tions were low-cost, had a long-term impact and were efficient in increasing awareness among users to improve safety, social inclusion and about transport schemes for older adults Improved transport infrastructure resulted in

a shift from private to public transportation For a sustainable urban transport infrastructure, good governance and involvement of stakeholders for planning and implementing transport interventions were considered necessary Lack

of evaluation, experience of transport planners, and inter-sectoral coordination were key challenges to successful interventions The review highlighted a lack of older adult-specific transportation policies, and gender-targeted inter-ventions for older women, suggesting a need for interinter-ventions and policies based on the contextual factors existing

in a region

Keywords: Age-friendly cities, Contextual factors, Older adults, Low- and middle-income countries, Urban

transportation, Public transport, Non-motorised transport, Transportation policies

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Introduction

Globally, there is a rapid growth in the aging popula-tion with a simultaneous rise in the number of older adults living in cities It is projected that between 2015 and 2050, the population of older adults above 60 years will increase from 12% to nearly 22% [1], intensifying the demand for better quality services in every sector, including urban transport A majority of the older adults

in low- and middle-income countries live in cities that

Open Access

*Correspondence: suzane109@gmail.com

1 Transdisciplinary Centre for Qualitative Methods, Department of Health

Information, Prasanna School of Public Health, Manipal Academy of Higher

Education, Manipal, India

Full list of author information is available at the end of the article

are not designed according to their needs, and for them

accessing essential services such as healthcare,

employ-ment and social life may involve commuting in unsafe,

irregular, and expensive transport services [2–5] The

transportation needs of older adults may vary

depend-ing on factors such as employment status, possession of

driver’s license, leisure activities etc If mobility is

hin-dered, it begins to affect their well-being [6] The

sus-tainable development goals, consisting of 17 goals, are a

plan of action which is interlinked to achieve a

sustaina-ble future for everyone across the globe by 2030 Among

them, sustainable development goals 3 and 11 are of

relevance for this review The third sustainable

devel-opment goal lays emphasis on ensuring healthy lives

and promoting well-being for everyone, including older

adults [7] In this context, safe and affordable mobility

infrastructures are key lifelines for older adults to reduce

transport-related social exclusion and improve access to

essential services required for maintaining a better

qual-ity of life [8–10] Available evidence also underscored the

linkages between improved transport infrastructure and

welfare outcomes of older adults For instance,

interven-tions such as improving transport infrastructure and

urban regeneration showed an improvement in mental

health and quality of life outcomes [11, 12]

Making cities sustainable by investing in public transport

through urban planning and management is a part of the

sustainable development goal 11 [7] However, in low- and

middle-income countries, which according to the World

Bank refers to countries classified under low-income,

lower-middle-income, and upper-middle-income

econo-mies [13], the urban residents, especially older adults, face

difficulties in accessing transportation that limits their

contributions to the society and the ability to lead

produc-tive lives [3 14] In recent years, to cope with rapid

urbani-sation, a few initiatives towards improving access and

safety in urban transport infrastructure have been

under-taken for older adults in different low- and middle-income

countries [15–17] Despite efforts from national and

inter-national agencies to address the needs of older adults

con-cerning public transportation (for e.g., bus rapid transit

systems, bus corridors with priority lanes, improvement

in public transport and non-motorised transport services)

inequalities faced by older adults while accessing urban

transport infrastructure are noticeable across regions [14,

18, 19] Subsidised fare made public transport affordable to

the most vulnerable population in Latin American

coun-tries such as Columbia and Chile [20] Similar

interven-tions can be adapted in other low- and middle-income

countries to make public transport accessible to older

adults irrespective of their income levels

It is evident that in low- and middle-income

coun-tries, implementation of interventions is limited by

context-specific social, economic, and political barriers [21, 22] In this light, comprehensive scientific informa-tion on the underlying mechanisms of why an interven-tion was successful or not to ensure equitable access for older adults to mobility infrastructure remained unexplored A deeper understanding of intervention mechanisms in the context of low- and middle-income countries can be provided through a theory-driven and interpretive approach, i.e., a realist review given by Paw-son and colleagues (2005) [23] Although this method has not been used previously to synthesise evidence in the area of transportation interventions, it has the potential

to provide comprehensive evidence to guide policy and practice in this area of research

A realist review encapsulates existing theory, evidence from previous research and stakeholder consultations in understanding the issues around the implementation of interventions with a contextual lens Realist reviews have been used in understanding complex interventions related

to health, housing, education etc [23, 24] Therefore, this realist review could help us identify the gaps in researched transportation interventions and the generated findings could guide policymakers to design projects or re-design the existing mobility services The following research ques-tions will be addressed through this review 1) what are the urban mobility infrastructure interventions and policies/ policy measures in low- and middle-income countries to improve the accessibility and safety of older adults? (2) How do contextual factors influence the success or failure

of such interventions and policies/policy measures?

For this review, we apply the following definitions:

1 Mobility refers to “movement in all of its forms, including basic ambulation, transferring from a bed

to a chair, walking for leisure and the completion

of daily tasks, engaging in activities associated with work and play, exercising, driving a car, and using various forms of public transport” [25]

2 For the purpose of this research, ‘Urban mobility structures’ refers to infrastructures (physical infra-structures in the cities) and services (e.g., public trans-port services running on the infrastructures), as well

as non-motorized transport (i.e., cycling and walking)

3 Transportation interventions in this research refer

to improvements made in public transportation and non-motorized transportation services and infrastructure, and the legal and economic policies outlined by the government with respect to trans-portation

4 Stakeholders for the current research include trans-port policymakers, transtrans-port intervention imple-menters, transport planners, urban planners (gov-ernment and private), transportation experts,

non-government organization, researchers, and older

adults from low- and middle-income countries

5 “Well-being includes the presence of positive

emo-tions and moods (e.g., contentment, happiness), the

absence of negative emotions (e.g., depression,

anxi-ety), satisfaction with life, fulfilment and positive

functioning” [26]

Methodology

The protocol for this review was registered with

the PROSPERO database (registration number:

CRD42020168020) The realistic review involved seven

phases explained below

Scoping the literature

An initial program theory was developed after

identi-fying the interventions and policy measures/policies

through preliminary literature search, and discussion

with stakeholders The program theory represented

in Fig. 1 shows how the implementation of transport interventions and policies influenced the outcomes such as improved health and well-being, better access

to healthcare, social life and employment, and cleaner environment The transport interventions were catego-rised as public transport interventions, non-motorized transport interventions, and transportation policies, which were influenced by various mechanisms con-tributing to their success or failure This program the-ory further helped inform the eligibility criteria and to develop the search strategy for a systematic search

Search process

A systematic and comprehensive search for empirical evidence was conducted on electronic databases such as Scopus, PubMed, ProQuest, Web of Science, EMBASE, JSTOR, Organisation for Economic Co-operation and Development library, Mobility in Cities, Transport

Fig 1 Program theory explaining the pathway of transportation interventions and policies and its outcomes

Research International Documentation, World Health

Organization-Institutional Repository for Information

Sharing, International Initiative for Impact Evaluation,

Sustainable Urban Transport Project, and Google Scholar

from inception until August 2020 The search strategies

and keywords used are given in additional file 1

Addi-tional literature from reference lists of included studies,

relevant review reports, conference proceedings,

doc-toral theses, and dissertations, were examined for

poten-tial studies Search was not restricted to publication type

but was limited to studies on humans and published in

English language

Selection and appraisal of documents

Study design

We included all relevant studies such as quantitative,

qualitative, mixed methods studies, literature reviews,

reports, theses, website articles, secondary data research

and systematic reviews that dealt with the issue of

improving the safety and accessibility of urban mobility

infrastructure

Population

We included all studies that informed about urban

mobility infrastructure interventions and policies/policy

measures in low- and middle-income countries for older

adults and all users (literature that included older adults

as subgroup)

Outcome

We included those studies that focused on the impact

of urban transport infrastructure interventions and

policies/policy measures on socio-economic

opportu-nities, well-being, and health Studies that did not give

sufficient information about the underlying

mecha-nisms of an intervention were excluded Studies that

focused only on specific age groups apart from older

adults were excluded Data was managed using Zotero

software [27]

Screening was undertaken based on title and abstract

initially by DSP and further it was assessed by UNY

This was followed by a full text screening initially by one

reviewer and assessed by a second reviewer Any

disa-greements were resolved by discussion The reasons for

exclusion have been recorded Quality assessment was

done by DSP and subsequently cross checked by UNY

The appraisal was based on the relevance and rigor of

a study, which is followed for a realist review We

con-sidered a study relevant if the data contributed in

build-ing the theory, and rigor of the study was assessed after

discussion within the review team regarding the

meth-ods used to generate data Only those studies which

established both rigor and relevance were included in the review

Data extraction

Data extraction sheet was pilot tested initially on few articles; subsequently the data extraction sheet was improved further before proceeding with data extraction Data were extracted by DSP and double-checked by UNY Any disagreements were resolved by discussion The data extraction sheet included details of study characteristics, intervention related information, details of the program theory and quality of the study

Analysis and synthesis process

The results are presented as per the Realist and

MEta-narrative Evidence Syntheses: Evolving Standards

report-ing guidelines (additional file 2) [28] The mechanisms that influenced the success and failure of interventions and transportation policies were synthesised and pre-sented narratively

Stakeholder consultation and refining the initial program theory

Stakeholder inputs are necessary for policymaking and are recommended for a realist synthesis [23] Stakehold-ers were consulted before starting the review, during the review process and after completing the review During

the review process, we consulted stakeholders (n = 12)

from India, Bangladesh, and Nepal, to understand their perspectives regarding urban mobility infrastructure interventions After sharing the initial review findings with them, online consultations were conducted The dis-cussion was recorded after obtaining consent and later transcribed The discussion involved their opinions about urban mobility infrastructure interventions and valida-tion of findings from the review Similarly, another online stakeholder consultation event was held to disseminate

the findings, which was attended by stakeholders (n = 17)

from India, Bangladesh, the United States of America, Norway and Indonesia The information was used to refine the program theory (Fig. 1)

Changes in the review process

Studies focusing only on transport interventions and policies for older adults were limited Hence, we used a broader search strategy and included studies that men-tioned ‘all users’ Any study that menmen-tioned ‘all users’ but did not include older adults was excluded

Results

A total of 36 studies met the inclusion criteria, of which

16 focused on urban mobility infrastructure interven-tions, and 20 were related to transport policy/ policy

measures The study selection process is shown in Fig. 2

Evidence was obtained from literature reviews (n = 18),

systematic reviews (n = 3), reports (n = 8), survey (n = 2),

case studies (n = 2), randomised controlled trial (n = 1),

mixed methods (n = 1), and qualitative content analysis

(n = 1) Evidence came from 5 low-income countries, 18

lower-middle-income countries, and 13

upper-middle-income countries The characteristics of included studies

are given in detail in table 1a and 1b (additional file 3)

Main findings

The review identified various transport interventions and

policies/ policy measures with respect to public transport

and non-motorised transport, which focused on

improv-ing infrastructure, safety, air quality, access to health care,

and employment and social services in low- and

middle-income countries Figure 3 summarises the interventions

identified with respect to public transport,

non-motor-ised transport, and transport policies, the mechanisms

that influenced them and the expected outcomes The

mechanisms such as individual factors are attributed to

older adults’ behaviour, literacy levels, awareness about

policies etc Systemic/ organisational factors include

the government agencies at local, state and country

levels, non-government organisations, and stakeholders involved in transport interventions In this review, infra-structural factors refer to the interaction between the sys-tems and organisations since they overlap For example, bus timing information and maintenance of infrastruc-ture are services offered by the transport organisations

Interventions and policies focused on older adults in low‑ and middle‑income countries

The review identified three transport interventions and one policy, specifically focusing on older adults This indicates that majority of the low- and middle-income countries do not plan transport policies and interven-tions explicitly for older adults Interveninterven-tions such as placing stickers with evocative messages (with or with-out images) inside the ‘Matatus’ or ‘mini buses’ along with a radio campaign in Kenya empowered older adults

to complain about rash driving, thus reducing accidents and having a safe commute [30] Likewise, ‘Boda-boda’ (motorcycle taxis) in Nigeria and South Africa helped older adults get access to remote areas, which helped them avail timely healthcare services and improved access to labour markets to sell their produce [31]

In Mexico, the pedestrian program ‘Camina’ showed

Fig 2 Document flow diagram *Adapted from: [29 ]

increased shift to active transport among older adults

[32] In addition, stakeholders’ consultation revealed that

countries such as Nepal and India had policies for fare

concession and reserved seats for older adults in buses

However, few older adults were unaware of these policies

Hence, pamphlet distributions in public places helped

increase awareness among older adults Tables 2a, 2b and

2c (additional file 4) give a detailed

context-mechanism-outcome configuration of transport interventions and

policies for all users, which included older adults as well

Mechanisms that influenced transportation interventions

in low‑ and middle‑income countries

Individual factors

The behaviour change communication interventions

such as using stickers with messages, messages aired

through radio and distributing pamphlets with messages

to increase awareness about safety while travelling in

public transport [30] were successful and influenced by

individual factors such as literacy and awareness about

transport services This when combined with

simulta-neous improvement in public transport (e.g., increased

frequency, electronic ticket system, condition of buses/

bus stops) and non-motorised transport infrastructure

(e.g., clean sidewalks, streetlights) resulted in behaviour

change among older adults The reviewed studies in countries like Mexico, African cities, India, Columbia, China, and Morocco showed a change in behaviour such

as increased walking for transport and increased use of public transport among users (including older adults) once their requirements regarding transport infrastruc-ture were met [30, 32–39] Similarly, to promote the

‘seat offering culture’ in public transport, a short film was disseminated in Wan Chai district, China, through social media platforms, holding tram parades and talks in schools This showed improved social inclusion of older adults, respect and age-friendliness in transportation [40]

On the other hand, illiteracy was seen as a barrier to the success of interventions, where stickers or pamphlets were used to educate people [30] Similar observation was made in China, where public information campaigns

to create awareness about pro-environmental travel behaviour helped in increasing the use of public trans-port and walking but did not have a sustainable long-term impact This was attributed to the lack of knowledge about transport services, a prerequisite for change in behaviours [19]

Stakeholder consultation during the review revealed that distribution of pamphlets and stickers in public

Fig 3 Mechanisms that influenced transportation interventions and policies

areas helped increase awareness among Nepal’s

pub-lic about reserved seats for older adults Transport

per-sonnel helped older adults get seats in the bus and gave

sufficient time for older adults to board and alight from

the bus However, emphasis was placed on the lack of

awareness among older adults in Nepal about the current

schemes, such as concessions in bus fares and designated

seats for older adults

Systemic and organisational factors

Transportation planning and policy demand good

governance for the use of existing resources and for

allocating new resources Our results highlight that

suc-cessful interventions for older adults to safely access

public transport mainly weighed on inter-agency

coordi-nation (local and state governments), adequate funding

from respective departments, proper planning,

imple-mentation and monitoring [36], strong commitment

from the local government, and stakeholder involvement

For example, China involved multiple bus agencies in

providing cost effective bus services The systemic and

organisational factors mentioned above led to the

suc-cessful implementation of bus rapid transit in China [32,

36, 38] Similarly, the government’s decision to expand

telecommunication services alongside the introduction

of Boda-Boda (motorcycle taxis) facilitated mobility and

access to healthcare and markets for older adults in

Nige-ria and South Africa [31]

However, a lack of trained personnel, corruption,

lim-ited experience in transport planning and

implementa-tion, and lack of awareness about the needs of older adults

to access transport infrastructure were barriers to

suc-cessful interventions For instance, the MyCiti project in

South Africa identified municipal capacities, operational

difficulties, teamwork, ethics, and geographical spread as

challenges for project implementation [41] In Pakistan,

although there were several policy measures planned to

improve transport infrastructure and to have an efficient

transport system the above mentioned factors acted as

barriers for the successful implementation [42, 43]

Consultation with stakeholders in Nepal indicated that,

the senior citizen’s act 2063 (2006) was passed by the

Nepal law commission due to the successful advocacy by

non-government organisations for fare reduction by 50%

and dedicated seats for older adults in public vehicles [44]

The other enabling factors identified during stakeholder

consultations were efficient management of metro rail

in Delhi, India and public consultation during the

feasi-bility stage for bus rapid transit and mass rapid transit in

Dhaka, Bangladesh However, the stakeholders also

high-lighted that lack of inter-agency coordination, funding,

absence of user-oriented thinking, lack of long-term

out-look while planning interventions, lack of knowledge for

the need to invest in low-cost solutions such as bus and non-motorised transport, and prioritising private vehicles were key challenges for a successful intervention In coun-tries like India, as mentioned by one of the stakeholders, lack of evaluation of the projects was an important factor for the failure of interventions For example, the metro projects were beneficial in bigger cities like Delhi; how-ever, planning for the metro without a proper feasibility check resulted in massive failure of metro projects in a few regions similar to the Jaipur metro project [45]

Infrastructure‑related factors

Improving the design of public transport and non-motorised transport, having good first mile and last-mile connectivity, bus rapid transit or bus priority lanes encouraged users to shift the mode of transport from private to public In India and Mexico, introducing the electronic ticketing system, comfortable seating arrange-ments in the buses and bus stations, proper bus shelters and exclusive bus lanes helped in reducing travel times and encouraged the older adults to use buses [35, 37] A study conducted in the United States of America, United Kingdom and Hong Kong showed similar findings, where older adults and persons with disabilities were more likely to use bus services when the design of the bus and bus stop improved [46] However, an unfriendly bus design, no concession in bus fare, and lack of designated seats for older adults pushed them to opt for other modes

of transport

Stakeholder consultation from India revealed that bus rapid transit was successful in various Indian cities like Ahmedabad, Surat, and Hubli-Dharwad due to the design

of the infrastructure It was suggested that bus rapid tran-sit was successful mainly in medium-sized cities, with good last-mile connectivity and short average trip lengths The success of a bus rapid transit depended on the selec-tion and design of the corridor The public bike-sharing project implemented in Mysore, India was another suc-cess story due to the dedicated lanes for cyclists and planned parking spaces In Bangladesh, new footpaths are being constructed, which are designed in a way that is friendly for older adults as well as for people with disabili-ties In Dhaka, Bangladesh, the lack of older adult friendly buses and dedicated seats, crowded buses and no conces-sion in bus fares have pushed the older adults to use the non-motorised rickshaws Additionally, the non-motor-ised rickshaws provide door-to-door delivery; hence, older adults preferred using them to the buses

Cultural context In Bangladesh, one of the

stakehold-ers mentioned that there are no dedicated seats for older adults in the bus; however, there is a cultural element about respecting older adults, hence when an older adult

enters the bus the younger people tend to offer them

their seat This cultural context is often seen in South

Asian countries In such regions, behavior change

com-munication interventions can be effective in educating

the younger generation to be more sensitive to the

trans-portation needs of older adults

Transportation policies and policy measures in low‑

and middle‑income countries

Road safety measures

Cities having a good rail transit network, road and vehicle

infrastructure, bicycle tracks, had lower rates of road

traf-fic injuries [47–51] Various transportation programmes

initiated in regions across Asia, South America, the

for-mer Soviet Union and low-income African countries,

did not focus on reducing motor vehicle use by

improv-ing non-motorised transport design Furthermore, there

was a lack of investment in safer public or active

trans-port alternatives other than cars, which are not affordable

to everyone [48] Policies that aimed at the construction

of new infrastructure to separate the pedestrians from

motor vehicles put vulnerable road users at higher risk of

crime, and jaywalking put the pedestrians at greater risk

[48] Despite extensive research conducted in Pakistan

on the importance of transport policies and their effect

on health, there have been no interventions suggested

for betterment This indicates a need for concentrated

efforts by the government and society to implement

nec-essary actions [52] The review identified that lack of legal

monitoring framework, unplanned urbanisation, absence

of suitable infrastructure, and a surge in motorisation

as challenges to improving road safety [51] In order to

determine new interventions to improve safety, there is

a need for reliable accident data, but we identified a lack

of reliable accident data in Asian countries due to

under-reporting, unlike the high-income countries where good

progress is made in the area of road traffic safety due to

capacity building, research and development [51]

There-fore, we recommend that low- and middle-income

coun-tries have a more robust system for recording accident

data in order to design new policies as per requirement

Thrust on access to healthcare, employment, and leisure

The review highlighted that subsidy in transport fare

resulted in better employment opportunities in South

Africa [53] and various transportation projects in Kenya,

Uganda and Ecuador helped improve access to

health-care and essential services [54] Similar findings were

observed in Seoul, South Korea where the introduction

of a fare-free subway policy for older adults resulted in

increased use of public transit than other transit modes

[55] Likewise, evidence from the United Kingdom shows

that the free bus pass scheme helped in increasing physi-cal activity and reducing social exclusion by giving older adults a sense of belonging in the community [56] Older adults in low- and middle-income countries may have varying degrees of financial hardships Hence, such ini-tiatives can be planned and implemented in low- and middle-income countries to increase the opportunities for older adults to access healthcare, work and leisure activities

Policy measures for improved environmental conditions and well‑being

Energy-efficient transport systems can be promoted

by developing mass rapid transit, upgrading the pub-lic transport (bus/tram), developing safe pedestrian and bicycle lanes and encouraging the use of small and highly efficient vehicles [52] Evidence from low- and middle-income countries showed that low carbon emissions combined with active travel policies (for e.g., promotional campaigns, change in physical infrastructure focused on safety, reduction in vehicle speed etc.) helped in reduc-tion of number of years of life lost due to ischemic heart disease, improved the health of individuals and a cleaner environment [57, 58] A shift to an active mode of trans-portation has shown health benefits among older adults such as reduced cardiovascular diseases in Canada and other European countries In addition, non-motorised transport has helped reduce emissions of harmful gases, reduced noise pollution and made neighbourhoods livea-ble for the residents [59–62] Therefore, it is important to promote active transport and transportation modes that are energy efficient to have a cleaner environment, which further enhances the well-being of older adults A multi-sectoral approach such as involving transport planners, public health, and environment experts is recommended while planning and implementing interventions

Measures to improve non‑motorised transport

Inadequate implementation of non-motorised transport specific policies in African countries was attributed to lack of an action plan, research and development, and monitoring and evaluation [63] In addition, budget allocation and lack of adequate space were other issues faced by low- and middle-income countries [64, 65] On

a positive note, under the sub-Saharan Africa transport policy programme, Nairobi successfully implemented interventions such as traffic calming measures, supply of bicycles, and building of special infrastructure for cyclists and pedestrians In recent years, non-motorised trans-port has been gaining popularity due to both health and environmental benefits However, the number of trips made using non-motorised transport is dependent on the quality of pedestrian pathways, and bicycle lanes [66]

Therefore, it is important for the transport sector to look

into the specific needs of older adults and design suitable

infrastructure accordingly

Discussion

This realist review summarised the findings of 36

arti-cles in 36 low- and middle-income countries on various

urban transport infrastructure interventions, why certain

interventions and policy measures were successful or not

successful It is important to identify and make note of

failures in the current interventions and policy

meas-ures, which restrain further progress At the same time

understanding the reasons for successful interventions

will help policymakers and transport planners design

interventions according to the context Sustainable

trans-port infrastructure, which promotes social inclusion and

safety will eventually have an impact on the well-being of

older adults [67, 68] Some of the key observations from

our review are discussed below

Behaviour change communication interventions are

affordable and have a better prospect at long term

sus-tainability It has been used effectively in various public

health and transport interventions to obtain desired

out-comes [69–73] For example, educational campaigns for

users through information kiosks in Brisbane and using

informative models of the stations and vehicles in Peru

before implementation of the project resulted in

bet-ter public acceptance of public transport [43] In the

context of this review, it was identified that educational

interventions alongside an improvement in transport

infrastructure helped in better acceptance of public

transport followed by a shift from private to public and

motorised to non-motorised transport It was observed

that an increase in public transport users

simultane-ously increased active transportation to access the public

transport transit stations [62, 74] Evidence from

devel-oped countries showed that an improvement in

trans-port infrastructure had subsequently increased walking

for transport, which helped in promoting physical

activ-ity for older adults resulting in their better well-being

[75–79] Likewise, empowering older adults to voice their

concerns helped reduce road accidents and thus

acci-dent-related injuries and fatalities due to rash driving

Additionally, sensitizing the public and transport

person-nel helped them to be more considerate towards older

people, further improving social inclusion of older adults

in public transport However, considering the fact that

illiteracy was a barrier to behaviour change

communi-cation interventions, more images rather than text

mes-sages could be used while communicating information

Inadequate funding in various low- and middle-income

countries acted as a barrier to the implementation of

inclusive transportation interventions In such situations,

it is beneficial to identify low-cost solutions to provide sustainable transport options Public–private partner-ship in transport interventions in China where multi-ple bus agencies were involved in bus rapid transit was found to be cost-effective Similarly, public–private part-nership initiatives in a few cities of developing countries like Latin America and Asia have shown significant ben-efits in urban public transport, especially with respect

to developing socially inclusive communities [80, 81] However, a few challenges with respect to public and private agencies were seen in Maharashtra, India, where public–private partnership initiatives have been taken up [82] Therefore, we recommend that contextual factors at systemic/ organization level should be considered before taking up public private partnership initiatives in other low- and middle-income countries [83]

The review brought to light that involvement of stake-holders during the projects’ design phase was lacking A case study from the city of Indore, India reported that the importance given to public outreach by the implement-ing authority contributed to the success of bus rapid tran-sit (iBus) in Indore [14] Hence, it is recommended that public consultation should be given importance before planning for projects Another important issue, which was highlighted during the stakeholder consultation was the lack of proper evaluation after the implementation

of the project New projects were planned even before evaluating the previous project Though bus rapid tran-sit is a low-cost project, suitable for medium-sized cit-ies, there is a [perhaps wrong] notion by the authorities that it is not feasible for countries like India and Bang-ladesh This suggests the importance of investing in low-cost solutions like bus rapid transit and non-motorised transport infrastructure Hence, a detailed evaluation

of implemented projects before drawing conclusions is strongly recommended for all transport infrastructure interventions

It was evident from the review as well as stakeholder consultations that policy initiatives were available for older adults, but the implementation of such policies are not up to the mark Therefore, many interventions

to improve infrastructure are not sensitive to the needs

of older adults There are universal accessibility guide-lines for all vulnerable groups, which may miss out few minor challenges faced by older adults According to the age-friendly cities guidelines, transportation is one

of the important domains affecting the well-being of older adults [84] Research emphasising the importance

of transport policies and health outcomes has been con-ducted, but a lack of commitment from the government

in engaging the community to design and implement interventions was observed in a few low- and middle-income countries A few stakeholders in our research

highlighted the importance of gender-specific targeted

interventions for older women Older women felt unsafe

while travelling on the public transport and walking alone

after it was dark due to thefts, inadequate street lighting,

lonely streets, and inappropriate behaviour of men on the

bus, for example sitting in the seats allotted for women

or standing closer to where women were sitting [85, 86]

Additionally, they faced challenges with the poorly

main-tained infrastructure of buses as well as walking pathways

due to frailty It is reported that older women are frailer

and have much higher incidents of falls compared to

older men [87–89] However, the review failed to identify

such interventions in low- and middle-income countries

specifically designed for older women, thus suggesting

the need to focus on transport interventions for older

women Policymakers could use recommendations from

available research, to design transport infrastructure with

a focus on older women

Strengths and limitations

The strength of this realist review is that it helped us

uncover the reasons for desired or undesired outcomes

of certain interventions, which were validated through

the valuable insights from stakeholders The

stakehold-ers were from government, private, non-government

organizations, and older adults, which gave a wide

range of opinions Using a theory-driven method and

systematic search of literature helped us in

understand-ing the key processes for successful interventions and

policy measures Transport planners, urban planners,

policymakers and relevant stakeholders can use these

findings for future urban transport interventions and

policies

The limitations of the study were as follows; First,

there was a lack of information regarding details of

evaluation of interventions in most of the studies This

informs that future research has to focus on

conduct-ing a robust evaluation of transport interventions

Sec-ond, the limited literature on interventions and policy

measures for only older adults resulted in modifying the

search strategy to ‘all users’, suggesting the need to

fur-ther explore in detail the mobility requirements of older

adults and how policymakers can improvise transport

interventions to make transport infrastructure inclusive

for older adults Third, stakeholders’ consultation was

limited to a few low- and middle-income countries only

due to the inability to get a response from those whom

we contacted (due to the pandemic) and time

con-straints, but this limitation was overcome by contacting

stakeholders who had rich experience of working on

dif-ferent transport projects in the low- and middle-income

countries

Conclusion and recommendations

An important implication for research is that there is a need of an implementation and evaluation plan for the interventions and policy measures in place More impor-tantly, local authors should use the evidence from previ-ous interventions/programs to design and implement the next one, or else the taxpayer’s money will not be well recognised To make the older adults feel included in a society it is important to re-think transportation policies and re-design the existing transport infrastructure to suit their mobility needs An integrated approach is necessary

in building age-friendly communities, which will improve the overall well-being of older adults Based on our find-ings, behaviour change communication approach was effective to increase awareness among individuals and improving the safety of users by reduction of road traffic injuries Efforts to collaborate with various stakeholders such as local administration, schools, community mem-bers and non-government organizations are important

to make the behaviour change communication approach effective Improving public transport and non-motorised transport infrastructure led to a shift from private to pub-lic mode of transport, which has a long-term impact on the well-being of individuals Therefore, ensuring good governance, coordination between departments, skilled personnel, adequate funding for project sustainability, and stakeholder consultation before planning any inter-vention will result in developing sustainable, cost effec-tive, and socially inclusive urban transport infrastructure

Supplementary Information

The online version contains supplementary material available at https:// doi org/ 10 1186/ s12889- 022- 13875-6

Additional file 1: Part A: Search keywords. The keywords were modi-fied for different databases as required Part B Search strategy and results Additional file 2 Table with RAMESES checklist.

Additional file 3: Table 1a Study characteristics- Transportation inter-ventions Table 1b Study characteristics- Transport policies and policy

measures.

Additional file 4: Table 2a Urban transport interventions (public trans-port) Table 2b Urban transport interventions (non-motorised transtrans-port).

Acknowledgements

The authors would like to acknowledge the technical support by Transdis-ciplinary Centre for Qualitative methods, Prasanna School of Public Health, Manipal Academy of Higher Education, during the course of the review

We would like to thank all the stakeholders from different regions for their valuable inputs We thank Ms Maria Matthew from the Department of Data Science, PSPH, MAHE, for proof reading and editing the document.

Authors’ contributions

All authors contributed to the conception and design of the research ques-tion, analysis and interpretation of data DSP and UNY were involved in data acquisition DSP drafted the initial version of the manuscript All authors criti-cally revised the intellectual content of the manuscript All authors have read and approved the final manuscript.